fallon community health plan, inc.smea.us/attachments/fallonfy11selectscheduleofbenefits.pdf ·...

07-670-375b_H800_0110

Fallon Community Health Plan, Inc.

Schedule of Benefits H800

This Schedule of Benefits is part of your Commonwealth of Massachusetts

FCHP Select Care Member Handbook. It describes your costs for health care.

Effective 7/1/2010 Copayments This plan includes three different office visit copayments. The amount of the office visit copayment you pay depends on the tiering level of the plan physician you visit. Tier 1*** (Excellent): Plan physicians practicing at an excellent level of quality and cost efficiency. Tier 2** (Good): Plan physicians practicing at a good level of quality and cost efficiency. Tier 3* (Standard): Plan physicians practicing at a standard level of quality and cost efficiency. Note: Quality measures were not used for tiering gastroenterology, hematology/oncology, neurology, nephrology, orthopedics, podiatry and urology. Only the efficiency ranking was used for these specialties.

• You have a $20 copayment for office visits with your PCP.

• You have a $15 (Tier 1), $20 (Tier 2) or $30 (Tier 3) copayment for prenatal and postnatal visits.

• You have a $25 (Tier 1), $35 (Tier 2) or $45 (Tier 3) copayment for office visits with specialty physicians.

• You have a $20 copay for office visits with the following plan specialists:

FCHP Select Care Schedule of Benefits H800

2 Questions? Contact FCHP Customer Service at: 1-866-344-4GIC (TDD/TTY: 1-877-608-7677) or at fchp.org.

− mental health and substance abuse providers

− chiropractors − physical and occupational therapists − speech-language pathologists and

audiologists − early intervention specialists − certified nurse midwives − optometrists (for routine eye exams only)

This plan includes a limit to the copayments you pay for inpatient admission copayments and outpatient surgery copayments. You are responsible for a maximum of four inpatient admission copayments and a maximum of four outpatient surgery copayments per year.

This plan includes a deductible. Your deductible is $250 per member/ $750 per family per calendar year for certain services. Once you have met your deductible, you may still be responsible for a copayment when you receive certain services. After you receive services, we will send you a letter indicating the amount that has been applied to your deductible.

This plan includes an out-of-pocket maximum for mental health and substance abuse outpatient copayments. You are responsible for an out-of-pocket maximum of $1,000 per member/ $2,000 per family in each year.

Services that require plan preauthorization The following covered services require preauthorization from the plan. Preauthorization must be requested by your PCP, or in some cases, your specialist.

• All elective admissions to a hospital or other inpatient facility

• Services with a non-FCHP Select Care network provider


Contact FCHP Customer Service at: 1-866-344-4GIC 3 (TDD/TTY: 1-877-608-7677) or at fchp.org.

• Organ transplant evaluation and services • Reconstructive and restorative services • Infertility/assisted reproductive technology

services • Oral surgery (with the exception of the extraction

of impacted teeth) • Genetic testing • Pain clinic • Neuropsychological testing • Prosthetics/orthotics and durable medical

equipment • Home health care and hospice care • Nonemergency ambulance

Diagnostic imaging services You have a $100 copayment for MRIs, CT scans and PET scans after you meet your deductible. This is limited to one copayment per day for these services.

The following chart shows your costs for covered services. These costs apply to the services in the Description of benefits section of your Commonwealth of Massachusetts FCHP Select Care Member Handbook. In summary, your responsibilities are as follows:



Covered services Benefit Ambulance services 1. Ambulance transportation for an

emergency Covered in full after you meet your deductible

2. Ambulance transportation for preauthorized nonemergency transfers

Covered in full after you meet your deductible

Durable medical equipment and prosthetic/orthotic devices Referral and plan authorization required for most services 1. The purchase or rental of durable

medical equipment and prosthetic/orthotic devices (including the fitting, preparing, repairing and modifying of the appliance)

20% coinsurance after you meet your deductible

2. Hearing aid(s). (Benefit available once every two years.)

The first $500 of the purchase price is covered in full; you pay 20% of the next $1,500 of the purchase price plus all additional costs. Up to a maximum benefit of $1,700.



Covered services Benefit Durable medical equipment and prosthetic/orthotic devices, continued 3. Scalp hair prosthesis (wigs) for

individuals who have suffered hair loss as a result of the treatment of any form of cancer or leukemia. Coverage is provided for up to $350 per member per calendar year when the prosthesis is determined to be medically necessary by a plan physician and the plan.

20% coinsurance

4. Breast prosthesis that is medically necessary after a covered reconstructive surgery following a mastectomy


5. Oxygen and related equipment 20% coinsurance after you meet your deductible

6. Insulin pump and insulin pump supplies

Covered in full



Covered services Benefit Emergency and urgent care 1. Emergency room visits

$100 copayment per office visit after you meet your deductible

2. Emergency room visits when you are admitted to an observation room


3. Emergency room visits when you are admitted as an inpatient


4. Urgent care visits in a doctor’s office or at an urgent care facility

$20 copayment per visit

5. Emergency prescription medication provided out of the FCHP Select Care service area as part of an approved emergency treatment

Tier 1: $10 copayment Tier 2: $25 copayment Tier 3: $50 copayment for up to a 14-day supply



Covered services Benefit Home health care services Plan authorization required 1. Skilled nursing care Covered in full

after you meet your deductible

2. Physical, occupational and speech therapy


3. Medical social services Covered in full after you meet your deductible

4. Home health aide services Covered in full after you meet your deductible

5. Medical and surgical supplies and durable medical equipment


6. Nutritional consultation Covered in full after you meet your deductible

7. Certain injectable medications that are administered in the home setting, when approved by FCHP and received through a plan-approved pharmacy vendor




Covered services Benefit Hospice care Referral and plan authorization required 1. Nursing care provided by or under the

supervision of a registered professional nurse (includes services provided by a home health aide)

Covered in full

2. Medical social services provided by a social worker

Covered in full

3. Outpatient physicians’ services provided by a doctor of medicine or doctor of osteopathy

Covered in full

4. Counseling services, such as dietary or bereavement, provided to the terminally ill individual and the family members or other persons caring for the individual at home

Covered in full

5. Short-term inpatient care for the control of pain and management of acute and severe clinical problems that cannot be managed in a home setting

$250 copayment per admission to hospital after you meet your deductible

Covered in full after you meet your deductible if admitted to a skilled nursing facility

Covered in full if admitted to hospice



Covered services Benefit Hospice care, continued 6. Medical appliances and supplies Covered in full

7. Physical therapy, occupational therapy and speech-language pathology services provided for purposes of symptom control or to enable the individual to maintain activities of daily living and basic functional skills

Covered in full

8. Prescription medication that is related to the terminal illness of the individual


Hospital inpatient services Referral and plan authorization required 1. Room and board in a semiprivate

room or a private room when medically necessary

$250 copayment per admission after you meet your deductible

2. The services and supplies that would ordinarily be furnished to you while you are an inpatient. These include but are not limited to diagnostic lab, pathology and X-ray services, anesthesia services, short-term rehabilitation, and operating and recovery room services


3. Physician and surgeon services




Covered services Benefit Hospital inpatient services, continued 4. General nursing services Covered in full

after you meet your deductible

5. Intensive and/or coronary care Covered in full after you meet your deductible

6. Dialysis services Covered in full after you meet your deductible

7. Medical, surgical or psychiatric services


8. Nursing services provided by a certified registered nurse anesthetist




Covered services Benefit Infertility/assisted reproductive technology (art) services* Referral and plan authorization required (unless provided by a Fallon Clinic specialist and you have a Fallon Clinic PCP) 1. Office visits for the consultation,

evaluation and diagnosis of fertility Tier 1: $25 copayment per visit Tier 2: $35 copayment per visit Tier 3: $45 copayment per visit

2. Diagnostic laboratory and X-ray services


3. Artificial insemination, such as intrauterine insemination (IUI)


4. Assisted reproductive technologies* Covered in full after you meet your deductible

5. Sperm, egg, and/or inseminated egg procurement, processing and banking, to the extent that such costs are not covered by the donor’s insurer


* See the Description of benefits section of your Member Handbook/Evidence of Coverage for a list of covered infertility/ART services.



Covered services Benefit Maternity services 1. Obstetrical services including prenatal,

childbirth, postnatal and postpartum care

Prenatal: Tier 1: $15

copayment Tier 2: $20


copayment first visit only

Postnatal: Tier 1: $15



copayment per visit

2. Inpatient maternity and newborn child care for a minimum of 48 hours of care following a vaginal delivery, or 96 hours of care following a Caesarean section delivery. The covered length of stay may be reduced if the mother and the attending physician agree upon an earlier discharge. If you or your newborn are discharged earlier, you are covered for home visits, parent education, assistance and training in breast or bottle feeding and the performance of any necessary and appropriate clinical tests; provided, however that the first home visit shall be conducted by a registered nurse, physician or certified




Covered services Benefit Maternity services, continued

nurse midwife; and provided further, that any subsequent home visit determined to be clinically necessary shall be provided by a licensed health care provider.

3. Charges for the following services when provided during an inpatient maternity admission: childbirth, nursery charges, circumcision, routine examination, hearing screening and medically necessary treatments of congenital defects, birth abnormalities or premature birth


Mental health and substance abuse services

Mental health care Inpatient services Plan authorization required

1. Room and board in a semiprivate room (or a private room when medically necessary) for respite, short-term residential, and hospital care only

Covered in full

2. The treatments and supplies that would ordinarily be furnished to you while you are an inpatient. These include but are not limited to individual, family and group therapies, pharmacotherapy, and diagnostic laboratory services.

Covered in full

3. Professional services provided by physicians or other licensed mental health professionals for the treatment of psychiatric conditions

Covered in full



Covered services Benefit Mental health care, continued Intermediate services Plan authorization required

1. Diversionary services such as day treatment/evening treatment and/or partial hospitalization for a full or partial day. Any of these services require authorization from the plan

Covered in full

Outpatient services 1. Outpatient office visits, including

individual, group or family therapy. The actual number of visits authorized beyond the initial eight is based on medical necessity as determined by the plan, and may include individual, group, or family therapy.


2. Psychopharmacological services, such as visits with a physician to review, monitor and adjust the levels of prescription medication to treat a mental condition


3. Neuropsychological assessment services when medically necessary


Substance abuse services Inpatient services Authorization required

1. Detoxification services for as many days as are required, based on medical necessity

Covered in full

2. Rehabilitation services including room and board in a semiprivate room and the services and supplies that would ordinarily be furnished to you while you are an inpatient.

Covered in full



Covered services Benefit Inpatient services, continued 3. Rehabilitation services in a day-

treatment setting

Covered in full

4. Room and board in a semiprivate room (or private room if medically necessary)

Covered in full

5. The services and supplies that would ordinarily be furnished to you while you are an inpatient. These include, but are not limited to, individual, group and family therapies and diagnostic/laboratory services.

Covered in full

6. Physician services such as medical and rehabilitation services for the treatment of alcohol or drug abuse

Covered in full

Intermediate services Plan authorization required

1. Diversionary services such as crisis intervention, day treatment/evening treatment, acute residential or other treatment as appropriate. Any of these services require authorization from the plan.

Covered in full

Outpatient services 1. Outpatient office visits to treat the

abuse of, or addiction to, alcohol and drugs. The actual number of visits authorized is determined by medical necessity, and may include individual, group and family therapies.

$20 copayment per office visit



Covered services Benefit Office visits and outpatient services 1. Office visits, to diagnose or treat an

illness or an injury PCP: $20 copayment per visit

Specialist: Tier 1: $25 copayment per visit Tier 2: $35 copayment per visit Tier 3: $45 copayment per visit

2. A second opinion, upon your request, with another plan provider

PCP: $20 copayment per visit


3. Injections and injectables that are included on the formulary, that are for covered medical benefits, and that are ordered, supplied and administered by a plan provider


4. Allergy injections Covered in full

5. Radiation therapy


6. Respiratory therapy




Covered services Benefit Office visits and outpatient services, continued 7. Hormone replacement services in the

doctor’s office for perimenopausal or postmenopausal women

Tier 1: $15 copayment per visit Tier 2: $20 copayment per visit Tier 3: $30 copayment per visit

8. Audiological examination for the purpose of prescribing a hearing aid. Coverage is limited to one exam every two years.


9. Diagnostic lab and X-ray services ordered by a plan provider, in relation to a covered office visit

Covered in full after you meet your deductible (with the exception of MRIs, CT scans and PET scans)

$100 copayment per MRI, CT scan or PET scan* after you meet your deductible

* Limited to one copayment per day for MRIs, CT scans and PET scans.



Covered services Benefit Office visits and outpatient services, continued 10. Electrocardiogram (EKG) Covered in full

11. Chiropractic services for acute musculoskeletal conditions. The condition must be new or an acute exacerbation of a previous condition. Coverage is provided for up to 12 office visits in each calendar year. The actual number of visits provided is based on medical necessity as determined by your plan provider and the plan.


12. Outpatient renal dialysis or continuous ambulatory peritoneal dialysis


13. Diabetes outpatient self-management training and education, including medical nutrition therapy, provided by a certified diabetes health care provider


14. Laboratory tests necessary for the diagnosis or treatment of diabetes, including glycosylated hemoglobin, or HbAlc, tests, and urinary/protein/ microalbumin and lipid profiles


15. Medical social services provided to assist you in adjustment to your or your family member’s illness. This includes assessment, counseling, consultation and assistance in accessing community resources.




Covered services Benefit Office visits and outpatient services, continued 16. Voluntary family planning services,

including:

• Consultations, examinations, procedures and medical services related to the use of all contraceptive methods; reproductive health education and disease prevention; genetic counseling; and elective sterilization

• Contraceptive devices that are supplied by an FCHP Select Care provider during an office visit

• Termination of pregnancy in an office setting

(Note: Termination of pregnancy or other procedures provided in a hospital outpatient, day surgery or ambulatory care facility are subject to the outpatient surgery copayment.)




Covered services Benefit Office visits and outpatient services, continued 17. Outpatient surgery, anesthesia and

the medically necessary preoperative and postoperative care related to the surgery

$125 copayment per surgery when provided in a hospital outpatient, day surgery or ambulatory care facility after you meet your deductible

When provided in an office: PCP: $20 copayment per visit


18. Visit to a contracted limited service clinic. Services are provided for a variety of common illnesses, including, but not limited to: • strep throat • ear, eyes, sinus, bladder and

bronchial infections • minor skin conditions (e.g.

sunburn, cold sores)




Covered services Benefit Oral surgery and related services Referral and plan authorization required (except for extraction of impacted teeth) 1. Removal or exposure of impacted

teeth, including both hard and soft tissue impactions, or an evaluation for this procedure


2. Surgical treatments of cysts, affecting the teeth or gums, that must be rendered by a plan oral surgeon


3. Treatment of fractures of the jaw bone (mandible) or any facial bone


4. Evaluation and surgery for the treatment of temporomandibular joint disorder when a medical condition is diagnosed, or for surgery related to the jaw or any structure connected to the jaw


5. Lingual frenectomy Tier 1: $25 copayment per visit Tier 2: $35 copayment per visit Tier 3: $45 copayment per visit



Covered services Benefit Oral surgery and related services, continued 6. Emergency medical care such as to

relieve pain and stop bleeding as a result of accidental injury to the sound natural teeth or tissues when provided as soon as medically possible after injury. This does not include restorative or other dental care. You do not need authorization for emergency care. Go to the closest provider.

Note: Benefits are provided for the dental services listed below only when the Member has a serious medical condition that makes it essential that he or she be admitted to a general hospital as an inpatient or to a surgical day care unit or ambulatory surgical facility as an outpatient in order for the dental care to be preformed safely. Serious medical conditions include, but are not limited to, hemophilia and heart disease.

Tier 1: $15 copayment per visit Tier 2: $20 copayment per visit Tier 3: $30 copayment per visit to a physician’s or dentist’s office.

$100 copayment per visit to an emergency room after you meet your deductible.

7. Removal of 7 or more permanent teeth




Covered services Benefit Oral surgery and related services, continued 8. Gingivectomies (including osseous

surgery) of two or more gum quadrants


9. Excision of radical cysts, affecting the roots of 3 or more teeth or gums, that must be rendered by a plan oral surgeon.


10. Removal of one or more impacted teeth.


Note: See Office visits and outpatient services for diagnostic lab and X-ray services.



Covered services Benefit Organ transplants Referral and plan authorization required 1. Office visits related to the transplant


2. Inpatient hospital services, including room and board in a semiprivate room and the services and supplies that would ordinarily be furnished to you while you are an inpatient*


3. Professional services provided to you while you are an inpatient, including, but not limited to medical, surgical and psychiatric services


4. Human leukocyte antigen (HLA) or histocompatability locus antigen testing for A, B or DR antigens, or any combination thereof, necessary to establish bone marrow transplant donor suitability of a member




Covered services Benefit Prescription drugs Covered prescription items:

• Prescription medication • Contraceptive drugs and devices • Hormone replacement therapy • Injectable agents (self-administered*) • Insulin • Syringes or needles (including insulin

syringes) when medically necessary • Supplies for the treatment of diabetes,

as required by state law, including: − blood glucose monitoring strips − urine glucose strips − lancets − ketone strips

Certain injectable medications administered in the home setting, when approved by FCHP and received through a plan-approved pharmacy vendor

* Injectables administered in the doctor’s office or under other professional supervision are generally covered as a medical benefit.

*A generic preferred program is now in place. This means that if you fill a prescription with a brand-name drug when a generic is available, you will be responsible for the generic drug copayment plus the cost difference between the two drugs.

Network pharmacy: Tier 1: $10 copayment Tier 2: $25 copayment Tier 3: $50 copayment for up to a 30-day supply

Mail-order pharmacy: Tier 1: $20 copayment Tier 2: $50 copayment Tier 3: $110 copayment for up to a 90-day supply



Covered services Benefit Preventive care 1. Routine physical exams for the

prevention and detection of disease $20 copayment per visit

2. Immunizations that are included on the FCHP formulary, that are for covered medical benefits and that are ordered, supplied and administered by a plan physician. If administered by a plan specialist, you will generally need to obtain a referral to see the specialist.

Covered in full

3. A baseline mammogram for women age 35 to 40, and a yearly mammogram for women age 40 and older

Covered in full

4. Routine gynecological care services, including an annual Pap smear (cytological screening) and pelvic exam


5. Routine eye exams, once in each 24-month period


6. Hearing and vision screening

Covered in full



Covered services Benefit Preventive care, continued 7. Well-child care and pediatric services,

at least six times during the child’s first year after birth, at least three times during the next year, then at least annually until the child’s sixth birthday. This includes the following services, as recommended by the physician and in accordance with state law: • physical examination • history • measurements • sensory screening • neuropsychiatric evaluation • development screening and

assessment


8. Pediatric services including: appropriate immunizations hereditary and metabolic screening at birth

newborn hearing screening test performed before the newborn infant is discharged from the hospital or birthing center

tuberculin tests, hematocrit, hemoglobin, and other appropriate blood tests and urinalysis

lead screening


9. Consultations, examinations, procedures and medical services related to the use of all contraceptive methods




Covered services Benefit Preventive care, continued 10. Contraceptive devices that are

supplied by an FCHP Select Care network provider during an office visit*

* Prescription contraceptive devices are covered under the prescription drug benefit.


11. Coronary artery disease secondary prevention program for members with a history of heart disease. This is a program that helps you reduce your heart disease factors through lifestyle changes. Members completing the program are eligible for a $100 reimbursement of the copayment amount. Contact Customer Service for more information.

$250 copayment

Reconstructive surgery Referral and plan authorization required (unless provided by a Fallon Clinic specialist and you have a Fallon Clinic PCP) 1. Office visits related to covered

reconstructive and restorative services Tier 1: $25 copayment per visit Tier 2: $35 copayment per visit Tier 3: $45 copayment per visit

2. Inpatient hospital services including room and board in a semiprivate room and the services and supplies that would ordinarily be furnished to you while you are inpatient


3. Professional services provided to you while you are an inpatient, including, but not limited to medical, surgical and psychiatric services




Covered services Benefit Rehabilitation services Referral and plan authorization required 1. Physical therapy to restore function

after medical illness, accident or injury. Coverage is provided for as many visits as are medically necessary per acute episode within a 90-day period per injury or illness, beginning with the first office visit. Visits after 90 days require prior authorization.


2. Occupational therapy to restore function after medical illness, accident or injury. Coverage is provided for as many visits as are medically necessary per acute episode within a 90-day period per injury or illness, beginning with the first office visit.


3. Treatment for acute episodes of an illness related to a chronic condition when the benefit limit has not been exceeded


4. Medically necessary services for the diagnosis and treatment of speech, hearing and language disorders when services are provided by an FCHP Select Care provider who is a speech-language pathologist or audiologist; and at an FCHP Select Care provider facility or FCHP Select Care provider’s office.




Covered services Benefit Rehabilitation services, continued 5. Cardiac rehabilitation services to treat

cardiovascular disease in accordance with state law and Department of Public Health regulations


6. Medically necessary early intervention services delivered by a certified early intervention specialist, according to operational standards developed by the Department of Public Health, for children from birth to their third birthday.

Covered in full

Skilled nursing facility services Referral and plan authorization required 1. Room and board in a semiprivate

room (or private room if medically necessary), for up to 100 days in each calendar year, provided criteria is met


2. The services and supplies that would ordinarily be furnished to you while you are an inpatient. These include, but are not limited to, nursing services, physical, speech and occupational therapy, medical supplies and equipment


3. Physician services




Covered services Benefit Special formulas Referral and plan authorization required 1. Special medical formulas to treat

certain metabolic disorders as required by state law. Metabolic disorders covered under state law include: phenylketonuria, tyrosinemia; homocystinuria; maple syrup urine disease; propionic academia; and methylmalonic academia in a dependent child, including when medically necessary to protect unborn fetuses of pregnant women with phenylketonuria.


2. Enteral formulas, upon a physician’s written order, for home use in the treatment of malabsorption caused by Crohn’s disease, ulcerative colitis, gastroesophageal reflux, gastrointestinal motility, chronic intestinal pseudo-obstruction, and inherited diseases of amino acids and organic acids


3. Food products that have been modified to be low in protein for individuals with inherited diseases of amino acids and organic acids. Coverage is provided for up to $5,000 per member in each calendar year. You may be required to purchase these products over the counter and submit claims to the plan for reimbursement.


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